C ollect classify and record required patient information Complete accurate orderly legible and permanent pen only This information may impact Diagnosis Treatment Nursing care ID: 932083
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Slide1
Patient Charts
Slide2Objective
C
ollect
, classify, and record required patient
information
Complete
, accurate, orderly,
legible, and permanent (pen only)
This information may impact:
Diagnosis
Treatment
Nursing care
Patient progress
Slide3Signalment
Systematic description of the patient
Patient Identification: name, chip number, tattoo, etc.
Species
Breed
Gender & reproductive status: neutered, spayed, intact
Age
Color
Markings: both genetic & acquired (ear notches, croppings, scars, etc.)
Slide4Client Information
Client name
Contact information
Address
Phone
Email
Emergency contact
If applicable:
Co-owner
Referring veterinarian
Slide5Presenting Chief Complaint
Reason for visit
Obtain a detailed narrative of events/behaviors leading to current health condition
Ask open ended questions
Record information in client’s own words
Distinguish between facts and interpretations – “Ranger is licking his paw” vs. “Ranger’s paw must hurt because he is licking it”
Slide6Presenting Chief Complaint
Onset of problem – when did it start
Anatomical location or body system
Character of problem:
Quality: what does it look like (i.e. hot swollen limb)
Severity
Duration: how long has the problem existed
Time of day: when does it usually occur
Frequency: how often does it occur
Triggers: what seems to start the problem, make it better/worse
Slide7Scenario 1
Chip is an 8-year-old male, intact Lhasa Apso belonging to Lisa Watkins (a long time client). She has brought Chip to the clinic because of a harsh cough whenever he is excited. This has been going on for about 6 months.
Slide8Scenario 1
Upon interviewing Ms. Watkins you learn that she has recently changed employment. What updates to her chart should be made and how? What else needs to be added to Chip’s chart?
Slide9Lisa Watkins
04/02/2016
123-45-6789
4568 Holly Lane
Seminole, TX 78954
Tom Jones
456 – 832-1598
x
Sally Field
3
1
2 llamas
Chip
x
Lhasa Apso
White & Brown
11/2008
x
DHLPP & Rabies 05/02/2015
456-832-4569
456-832-9584
Chip’s Chart
Monthly heartworm preventative
Adult maintenance dry dog food
Slide10Lisa Watkins
04/02/2016
123-45-6789
4568 Holly Lane
Seminole, TX 78954
Tom Jones
456 – 832-1598
x
Sally Field
3
1
2 llamas
Chip
x
Lhasa Apso
White & Brown
11/2008
x
DHLPP & Rabies 05/02/2015
456-832-4569
456-832-9584
Chip’s Updated Chart
Coughing when excited for about 6 months
X
Monthly heartworm preventative
Adult maintenance dry dog food
456-832-2223
tw
Slide11Scenario 2
“
Stormlight
”,
a
14 year-old Hanoverian gelding, was recently purchased by new clients Dorothy and Steve Brown. This sale is contingent upon a normal wellness exam. They have called to schedule an appointment and would particularly like to assess any potential lameness issues.
Slide12Scenario 2
Consider the information which should be included on a new client/patient chart and complete as much as you can based on the scenario details. What additional information would you need to obtain?
Slide13Fill in the Blanks!
Slide14Stormlight
Eq
Hanoverian
Bay
3 socks & blaze
03/15/2002
M
Y
Wellness/lameness exam
04/02/2016
04/22/1986
Steve Brown
704-022-0161
102 Timber Creek
704-802-2016
Palo Pinto
TX
76484
704-802-8516
Texas
AgriLife
Extension
sbrown@tae.com
7048 Pinto Drive
Research associate
704-80-201
Wind Swept Farms
Dorothy Brown
704-802-2010
Completed Chart
Slide15Questions?